From the Department of Surgical Oncology, University of Texas MD Anderson Cancer Center, Houston, TX.
J Am Coll Surg. 2023 Jul 1;237(1):4-12. doi: 10.1097/XCS.0000000000000652. Epub 2023 Feb 14.
The use of risk-stratified pancreatectomy care pathways (RSPCPs) is associated with reduced length of stay (LOS). This study sought to evaluate the impact of successive pathway revisions with the hypothesis that high-risk patients require iterative pathway revisions to optimize outcomes.
A prospectively maintained database (October 2016 to December 2021) was evaluated for pancreaticoduodenectomy patients managed with RSPCPs preoperatively assigned based on postoperative pancreatic fistula (POPF) risk. Launched in October 2016 (version [V] 1), RSPCPs were optimized in February 2019 (V2) and November 2020 (V3). Targeted pathway components included earlier nasogastric tube removal, diet advancement, reduced intravenous fluids and opioids, institution-specific drain fluid amylase cutoffs for early day 3 removal, and patient education. Primary outcome was LOS. Secondary outcomes included major complication (Accordion grade 3+), POPF (International Study Group for Pancreatic Surgery Grade B/C), and delayed gastric emptying (DGE).
Of 481 patients, 234 were managed by V1 (83 high-risk), 141 by V2 (43 high-risk), and 106 by V3 (43 high-risk). Median LOS reduction was greatest in high-risk patients with a 7-day reduction (pre-RSPCP, 12 days; V1, 9 days; V2, 7 days; V3, 5 days), compared with low-risk patients (pre-pathway, 10 days; V1, 6 days; V2, 5 days; V3, 4 days). Complications decreased significantly among high-risk patients (V1, 45%; V2, 33%; V3, 19%; p < 0.001), approaching rates in low-risk patients (V1, 21%; V2, 20%; V3, 14%). POPF (V1, 33%; V2, 23%; V3, 16%; p < 0.001) and DGE (V1, 23%; V2, 22%; V3, 14%; p < 0.001) improved among high-risk patients.
Risk-stratified pancreatectomy care pathways are associated with reduced LOS, major complication, Grade B/C fistula, and DGE. The easiest gains in surgical outcomes are generated from the immediate improvement in the patients most likely to be fast-tracked, but high-risk patients benefit from successive application of the learning health system model.
使用风险分层的胰切除术护理路径（RSPCP）与缩短住院时间（LOS）有关。本研究旨在评估连续路径修订的影响，并假设高危患者需要迭代路径修订以优化结果。
对 2016 年 10 月至 2021 年 12 月期间接受 RSPCP 管理的胰十二指肠切除术患者的前瞻性维护数据库进行评估，术前根据术后胰瘘（POPF）风险进行 RSPCP 分组。该研究于 2016 年 10 月启动（版本[V]1），并于 2019 年 2 月（V2）和 2020 年 11 月（V3）进行了优化。针对性的路径组件包括更早地拔除鼻胃管、饮食进步、减少静脉输液和阿片类药物、机构特定的引流液淀粉酶截止值用于第 3 天早期拔除引流管，以及患者教育。主要结果是 LOS。次要结果包括主要并发症（Accordion 分级 3+）、POPF（国际胰腺外科研究组分级 B/C）和延迟胃排空（DGE）。
在 481 名患者中，234 名患者接受了 V1（83 名高危）治疗，141 名患者接受了 V2（43 名高危）治疗，106 名患者接受了 V3（43 名高危）治疗。高危患者的 LOS 减少幅度最大，与低危患者相比，高危患者的 LOS 减少了 7 天（术前 RSPCP 为 12 天，V1 为 9 天，V2 为 7 天，V3 为 5 天）。高危患者的并发症显著减少（V1，45%；V2，33%；V3，19%；p < 0.001），接近低危患者的水平（V1，21%；V2，20%；V3，14%）。高危患者的 POPF（V1，33%；V2，23%；V3，16%；p < 0.001）和 DGE（V1，23%；V2，22%；V3，14%；p < 0.001）也有所改善。
风险分层的胰切除术护理路径与 LOS、主要并发症、B/C 级瘘和 DGE 减少有关。最有可能快速康复的患者的手术结果立即改善，这是最容易获得的，但高危患者受益于学习健康系统模型的连续应用。
